Neoadjuvant and adjuvant strategies for pancreatic cancer.

Pancreatic cancer is one of the major causes of cancer death. The majority of patients present with advanced disease and only 10-15% of patients can undergo resection. Survival after curative surgery is poor, as recurrences occur either locally or in the liver. Adjuvant therapy aims to improve survival and control systemic disease. Based on the results from the ESPAC-1 and Oettle studies, there is a significant survival advantage with 5-fluorouracil/folinic acid and a survival advantage trend with gemcitabine compared to surgery alone. The survival advantage of adjuvant chemotherapy is still observed when incorporated into an individual patient data meta-analysis. Based on the EORTC and ESPAC-1 trial results there is no significant evidence for the use of adjuvant chemoradiation. The use of chemoradiation with follow on chemotherapy, has not been shown to be superior to chemotherapy alone based on the results of the underpowered 1987 GITSG study and a recent combination study from the USA. The standard of care for adjuvant therapy based on level I evidence (from the ESPAC-1 trial) is postoperative chemotherapy using 5-fluorouracil with folinic acid providing a best estimate of 29% 5-year survival.